Prolonged video EEG monitoring in differential diagnosis of seizures and in presurgical epilepsy diagnosis]

Prolonged video-EEG-monitoring facilitates a correlation of clinical seizure semiology and corresponding EEG changes. Indications for prolonged video-EEG-monitoring comprise differential diagnosis of epileptic and psychogenic seizures, correct classification of epileptic syndromes and presurgical evaluation of patients with medically refractory focal epilepsies. 6000 patients in Austria would benefit from epilepsy surgery with an additional 150 bis 200 new patients appearing each year. Presurgical evaluation consists of a non-invasive Phase I and an invasive Phase II. During Phase I each patient is evaluated with a prolonged video-EEG-monitoring with scalp-EEG, a MRI-scan, a SPECT- and/or PET-scan, a neuropsychological evaluation and a Wada-test. If the epileptogenic zone cannot be localized adequately with these methods, invasive electrophysiological techniques with intracranial (epidural peg-electrodes, foramen-ovale electrodes, subdural strip or grid electrodes) or intracerebral electrodes (stereotaxically implanted depth electrodes) have to be applied. Epilepsy surgery renders 70 to 80% of patients seizure free and thus can regarded an effective and safe treatment option for patients with medically refractory focal epilepsies.     

Case of simple partial status epilepticus in occipital lobe epilepsy misdiagnosed as migraine: clinical, electrophysiological, and magnetic resonance imaging characteristics

An 31-year-old man had a unique form of occipital lobe epilepsy. Since age 13 years, he has had episodes of simple partial status epilepticus (SE) occurring twice a month. These typically consisted of elementary visual hallucinations of flashing lights obscuring his left visual field for a period of 2 days, associated with a severe frontal headache initially diagnosed as migraine. These episodes of simple partial SE then evolved to a complex partial seizure (CPS) or secondarily generalized seizure. There were unique EEG features, including: (a) the perception of a flash of light in the left visual field with a single sharp/slow wave discharge over the right occipital lobe, (b) right occipital lobe epileptiform activity during the prolonged aura, and (c) an abnormal response to photic stimulation, with occipital lobe discharges during low rates of stimulation (3-5 Hz), time-locked to the stimulus. High-resolution magnetic resonance imaging (MRI) with quantitative morphometry demonstrated that the right hemisphere and right caudate nucleus were smaller than those on the left. An abnormal gyral pattern was also noted over the right parietal region. Occasionally, distinguishing occipital lobe epilepsy from migraine may be difficult.     

Is partial epilepsy progressive? Ten-year follow-up of EEG and neuropsychological changes in adults with partial seizures

PURPOSE: This study was undertaken to determine what changes, if any, occur in the electroencephalogram (EEG) and in neuropsychological test findings of adults with medically intractable complex partial epilepsy over a 10-year period. METHODS: We studied 35 adults, with a mean age of 32 years (range, 16-59 years) at time of initial testing. We compared the distribution of epileptiform patterns documented on the initial pair of waking and sleeping EEGs to those observed on another pair obtained 10 years later. During this same 10-year period, we also examined changes in the Wechsler Adult Intelligence Scale (WAIS) and on the tests from the Neuropsychological Battery for Epilepsy. RESULTS: The EEGs of 28 (80%) of patients at the tenth year were identical to those seen initially. Five (14%) of patients demonstrated EEGs after 10 years with either no discharges or only unilateral discharges, where bilateral discharges were seen a decade earlier. Only two (6%) of patients had EEGs at the tenth year that showed bilateral discharges where only unilateral discharges were seen originally. We found no general change in intelligence or neuropsychological functioning after 10 years, although a few subtle losses were noted on several neuropsychological measures. CONCLUSIONS: For most adults with medically intractable complex partial epilepsy, the EEG and neuropsychological test scores remain reasonably stable over a decade.     

Occurrence, causes and clinical characteristics of status epilepsy in adults

INTRODUCTION: Status epilepticus, particularly grand mal, is one of the gravest and most dramatic conditions in neurology requiring immediate attention. Status epilepticus can occur in epileptic patients, often with higher mortality rates in symptomatic than idiopathic, but also as an initial symptom of a number of neurological and systemic diseases. No data are available on the exact incidence rates of status epilepticus. According to some assessments, 10% of patients have at least one status epilepticus in their lifetime (3,6). The prognosis mostly depends on the main cause, time in which seizures are stopped and age of patients. Latest data available in literature suggest the mortality rate of 2-8%. MATERIALS AND METHODS: We analyzed frequency of hospital admissions, causes and clinical characteristics of status epilepticus in adults. The study was retrospective, based on case histories of epileptic patients from the Intensive Care Unit of the Neurology Clinic in Novi Sad in 1990, 1993 and 1995. Special emphasis was placed on differences in studied parameters between cases confirmed earlier and those with status epilepticus occurring as an initial symptom of some other illness or condition. RESULTS: Number of hospital admissions rose slightly in the interval observed in comparison with total admissions (0.68% in 1990, 1.24% in 1993, and 1.73% in 1995) (Tabs 1 and 2). During 1993, status epilepticus was more frequent in cases confirmed earlier (69%) compared with the years 1990 (56%) and 1995 (43%) (Graf.1). Epileptic patients were younger on the average than nonepileptic ones (Tab. 3). Status epilepticus occurred more often in male patients (Tab. 4). Irregular treatment was the prevailing cause in epileptic patients (Tab 5). Symptomatic status epilepticus was reported higher in 1990 and 1995, and stroke was definitely the predominant cause (Tab 6). Convulsive grand mal status prevailed in all patients (Graf 2). Focal status was a more frequent finding in nonepileptic patients (Graf 3). Every third in 16 patients died in 1993 and every fifth in 23 in 1995 probably due to the acute destructive brain damage rather than the status itself. No deaths occurred in 1990. DISCUSSION: According to research carried out by other authors, half of grand mal status cases occurred in confirmed epileptics (4). In our study the grand mal status was reported in 70.4% cases of epilepsy. Primary cause was abrupt withdrawal of antiepileptic treatment, infections, alcohol abuse and use of convulsive drugs. This is compatible with our results which confirm that grand mal status either primary or with secondary generalization prevail in both groups of patients (7,8,9). In terms of causes of status epilepticus in nonepileptic patients, literature data mainly suggest cerebral trauma, frontal brain tumors, cerebral arteriosclerosis or other vascular disorders and anaphylaxis (4). Our results point to stroke as the major cause of status epilepticus in nonepileptic patients, similar with data presented by Towne (10). There is no data in literature concerning the relation between sex of patients and occurrence of status. In our study status epilepticus occurred more frequently in male patients. CONCLUSION: The grand mal status was the major clinical type of status in all patients and was primarily caused by discontinued or irregular antiepileptic treatment in patients with confirmed epilepsy, and by stroke in nonepileptic patients.     

Initial and follow-up brain MRI findings and correlation with the clinical course in Wilson's disease

We performed pretreatment brain MRIs in 25 patients with neurologically symptomatic Wilson's disease (WD) and clinical and MRI follow-up in 16 of them. All 25 pretreatment MRIs revealed abnormalities, with abnormal high-signal intensity (HSI) in bilateral thalami being the most common (92%). HSI lesions in the brainstem (84%) and the basal ganglia (72%) were also common. Brain atrophy was present in 88% of the 25 patients. In the follow-up period of 5 to 24 months, during which the patients were treated with D-penicillamine, both HSI lesions and neurologic symptoms improved in 88% of the 16 patients, but the brain atrophy did not change.     

Unilateral proptosis in an immunocompetent man as the initial clinical manifestation of systemic Hodgkin disease

OBJECTIVE: Orbital involvement in Hodgkin disease (HD) is rare. Previously reported cases of HD in patients without the acquired immunodeficiency syndrome have been diagnosed late in the course of established systemic disease. The authors describe an immunocompetent man with orbital infiltration as the initial manifestation of systemic HD. DESIGN: Case report. PARTICIPANTS: A 47-year-old man with acute progressive, painless proptosis of the left eye is described. INTERVENTION: A well-defined, homogeneous soft tissue mass of the superior left orbit was evident on computed tomography, and an incisional biopsy of the nontender mass was performed. RESULTS: The histopathologic findings were characteristic of HD. Systemic investigations showed clinical stage 3A HD. Ten months after completion of hybrid chemotherapy, the patient remained in complete remission from his HD. CONCLUSION: Hodgkin disease presenting initially in the orbit of a patient with the acquired immunodeficiency syndrome has been described previously. The patient presented in this report is the first case of HD in the recent English literature with the initial manifestation in the orbit of an otherwise immunocompetent patient.     

FDG-PET and volumetric MRI in the evaluation of patients with partial epilepsy

We performed interictal FDG-PET- and MRI-based hippocampal volumetric measurements on 18 adult patients with complex partial epilepsy of temporal lobe origin in whom we had identified their ictal focus by video-telemetry EEG. Sixteen patients (89%) had regional hypometabolism, 11 (61%) had focal 1.5-tesla T2-weighted MRI (two structural abnormalities, nine hippocampal formation [HF] increased T2 signal), and nine (50%) had absolute HF atrophy ipsilateral to the temporal ictal focus. Ten (55%) had abnormal L/R HF ratios, nine ipsilateral to the EEG focus. All patients with abnormal MRI volumetric studies had focal PET abnormalities. Only seven had both abnormal HF volume ratios and T2 MRI (all increased HF T2 signal). There was a significant correlation between hippocampal volume and inferior mesial and lateral temporal lobe cerebral metabolic rate of glucose asymmetry index (p < 0.01), suggesting that hypometabolism may reflect hippocampal atrophy. PET is more sensitive than MRI volumetry in identifying the ictal focus but does not provide additional information when HF atrophy is present.     

Functional status and well-being in a placebo-controlled trial of zidovudine in early symptomatic HIV infection

To determine the effect of zidovudine on functional status and well-being in patients with early symptomatic human immunodeficiency virus (HIV) infection, 70 subjects in a randomized, placebo-controlled trial (ACTG Protocol 016) were observed for 1 year using a brief quality-of-life questionnaire. Thirty-four subjects were assigned to placebo and 36 subjects to zidovudine, 200 mg orally every 4 h (1,200 mg daily). Functional status and well-being were measured every 3 months using a 30-item self-administered questionnaire derived from health ratings from the Medical Outcomes Study. The mean changes from baseline for zidovudine versus placebo groups were compared using paired and two-sample t tests. Subjects receiving a placebo reported better quality of life compared to baseline than subjects receiving zidovudine at 24 weeks for all dimensions of well-being, including overall health, energy, mental health, health distress, pain, and quality of life. The difference between the two groups' changes from baseline for overall health was 11.5 points on a 100-point scale (p = 0.02), and 11.1 points for energy (0.002). There were no differences between changes from baseline along various dimensions of functional status (physical, social, role, and cognitive function). At 52 weeks both groups reported worse overall health than at baseline, and changes in scores were more similar for the two groups. Although zidovudine has previously been demonstrated to delay progression of disease for patients with mildly symptomatic HIV infection, early in treatment the net effect of a 1,200 mg daily dose of zidovudine may diminish patients' subjective well-being.(ABSTRACT TRUNCATED AT 250 WORDS)     

Culture of endothelial cells as an in vitro model for experimental and clinical research]

Culture of endothelial cell is gotten from human umbilical cord by enzymatic digestion. For the growth of cells in culture, medial RPMI 1640 with 20% mixed human serum (NHS) or 20% fetal calf serum (FCS), endothelial cell growth factor (ECGF) and heparin have been used. Plastic, 0.1% gelatin and fibronectin have been used as a fundament. Immune identification of endothelial cells was culture is performed by monoclonal antibodies on vWF:Ag. Homogeneous cell line in culture might be used as in vitro model in both experimental and practice work.     

The incidence and clinical manifestation of food allergy in unselected Polish infants: follow-up from birth to one year of age

This study was intended to evaluate the incidence of atopic diseases and spectrum of clinical allergic manifestation in Polish infants from North-East region of Poland in relation to genetic hereditance. The infants included in the study were unselected, born consecutively during the first three months of 1993. It was demonstrated that 39% of infants developed an atopic disease during first year of life, 70% in high-risk of allergy group and 18% in low-risk of allergy group. The difference was statistically significant (p < 0.0005). The common atopic manifestation in children was atopic dermatitis. It was recorded in 70% of babies with and in 12% of babies without a family history of atopy.     

L-deprenyl as an adjunct to low-dose bromocriptine in early Parkinson''s disease: a short-term, double-blind, and prospective follow-up study

The potential role of allergen-specific IgG antibodies as 'blocking' antibodies in allergen-induced human basophil histamine release was investigated. This was studied in a model with the major grass pollen allergen Lol p I and polyclonal rabbit antisera directed against this allergen and against a synthetic peptide of its C terminus. When allergen and antibodies were allowed to preincubate, Lol p I induced histamine release was inhibited up to 85% by the antiserum against Lol p I. By omitting preincubation, and thereby more closely mimicking an in vivo situation, up to 55% inhibition was realized. This indicates that allergen-specific IgG can act as 'blocking' antibody without preincubation. Immunization of rabbits with a synthetic C-terminal peptide of Lol p I resulted in antibodies reactive with natural Lol p I. Despite their 100-fold lower avidity for Lol p I (as compared with antinatural Lol p I), these antibodies had the capacity to inhibit Lol p I induced histamine release for > 90% (up to 50% without preincubation). This indicates that it is possible to block histamine release induced by a major allergen with low-avidity IgG antibodies directed against a minor proportion of the allergen (25 amino acids). IgE antibodies from the donors studied were unreactive with this synthetic peptide, indicating that for blocking activity identical epitope specificity of IgE and IgG is not essential. This opens interesting perspectives for application of synthetic peptides in immunotherapy, distinct from their effects on T cell reactivity.     

Relationship between imaging and pathological features and clinical factors in surgical cases of temporal lobe epilepsy]

The advantages of the free TRAM flap over the conventional Tram flap are known. The use of its main pedicle--the deep inferior epigastric system--improves the blood supply, decreasing the risk of skin and fat necrosis. The harvesting of 5-7 cm of muscle, and the preservation of its lateral border decreases the risk of abdominal wall bulge or hernias. Delayed breast reconstructions in patients submitted to radiotherapy were performed by end to side anastomosis between flap vessels and axillary vessels, avoiding the thoracodorsal irradiated vessels, and improving the blood flow. Ten patients were submitted to breast reconstruction by free TRAM flaps. There was one total flap necrosis, and one delayed healing around the periumbilical suture. Neither skin nor fat necrosis were seen. One patient developed an abdominal wall bulge. Two patients presenting tumor metastasis abandoned the plastic surgery outpatient clinic. Two patients refused the nipple-areolar complex (NAC) reconstruction. The outcome of five NAC reconstructions was very good, breasts being symmetrical without an opposite breast operation.     

Patient satisfaction with surgical treatment of refractory epilepsy done in childhood and early adolescence

The results of a retrospective self-controlled telephone satisfaction survey of 63 patients who had undergone an earlier resection for the treatment of medically refractory epilepsy before the age of 18 years was reported. The survey items consisted of a global rating scale and a series of open-ended questions about positive and negative outcomes as a result of the surgery. Most (80%) of the patients felt the surgery had had a positive effect on their lives. The mean global score was 6.24+2.4 (scale 0-9). Strong positive correlations were found between seizure control and degree of satisfaction and between perceived postsurgical neurological deficits and dissatisfaction.     

Carcinoma of the larynx in an 11-year-old boy with late cervical metastasis: report of a case with a ten-year follow-up

An 11-year-old boy with laryngeal carcinoma underwent a partial laryngectomy. Subsequently, a cervical metastatic node developed eight months following a tonsillectomy; a radical neck dissection was performed. The patient has remained free of disease over a ten-year follow-up period. In our review of the English literature, no similar case report was found. The potential relationship of tonsillectomy to alterations in local T cell-mediated immune response is discussed.